Abstract
BackgroundImpaired microvascular perfusion is central to the development of coma and lactic acidosis in severe falciparum malaria. Refractory hypotension is rare on admission but develops frequently in fatal cases. We assessed cardiac function and volume status in severe falciparum malaria and its prognostic significance.MethodsPatients with severe (N = 101) or acute uncomplicated falciparum malaria (N = 83) were recruited from 2 hospitals in India and Bangladesh, and healthy participants (N = 44) underwent echocardiography.ResultsPatients with severe malaria had 38% shorter left ventricular (LV) filling times and 25% shorter LV ejection times than healthy participants because of tachycardia; however, stroke volume, LV internal diameter in diastole (LVIDd), and LV internal diameter in systole (LVIDs) indices were similar. A low endocardial fraction shortening (eFS) was present in 17% (9 of 52) of severe malaria patients. Adjusting for preload and afterload, eFS was similar in health and severe malaria. Fatal cases had smaller baseline LVIDd and LVIDs indices, more collapsible inferior vena cavae (IVC), and higher heart rates than survivors. The LVIDs and IVC collapsibility were independent predictors for mortality, together with base excess and Glasgow Coma Scale.ConclusionsPatients with severe malaria have rapid ejection of a normal stroke volume. Fatal cases had features of relative hypovolemia and reduced cardiac index reserve.
Highlights
MethodsPatients with severe (N = 101) or acute uncomplicated falciparum malaria (N = 83) were recruited from 2 hospitals in India and Bangladesh, and healthy participants (N = 44) underwent echocardiography
Impaired microvascular perfusion is central to the development of coma and lactic acidosis in severe falciparum malaria
Reduced microcirculatory perfusion resulting from microvascular obstruction by sequestered parasites is central to the development of coma and lactic acidosis [3, 4]
Summary
Patients with severe (N = 101) or acute uncomplicated falciparum malaria (N = 83) were recruited from 2 hospitals in India and Bangladesh, and healthy participants (N = 44) underwent echocardiography. Consecutive consenting patients admitted to the adult medical wards during the malaria seasons at Chittagong Medical College Hospital (CMCH), Chittagong, Bangladesh in 2011– 2014 and ISPAT General Hospital (IGH), Rourkela, India in 2011 with severe or uncomplicated falciparum malaria as defined previously [17] were enrolled into a pathophysiology study. Further details can be found in the Supplementary Methods. All patients had a medical history taken, full clinical examination, blood draw, and echocardiography performed on enrollment and were followed up at least once every 6 hours. Full details of echocardiographic procedures are provided in the Supplementary Methods
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